Shining a Light on Patient Safety in the OR

This is a true story, some details have been changed to protect patient and organizational confidentiality.

A Cautionary Tale: Navigating Patient Safety Challenges

Patient safety has always been a cornerstone of healthcare delivery, yet recent trends demand heightened attention. The challenges of workforce shortages, diminished experience levels, increased reliance on agency staff, and ongoing financial pressures have created a precarious environment for hospitals worldwide. In this context, I offer a reflection grounded in over 20 years of healthcare operations leadership, alongside a personal experience that shaped my commitment to patient safety.

The Flashlight That Saved a Life

Years ago, when I was a Certified Registered Nurse Anesthetist (CRNA), the Joint Commission Universal Protocol ("surgical timeout"), was relatively new and not routine in all hospitals. While working  one Friday afternoon, during the 3 p.m. shift change—a time when fatigue and the weekend mindset often crept in—I entered an operating room to offer a break to the on-duty CRNA. The patient was already under anesthesia, the surgical site prepped and draped. Loud music played in the background, the room lights were off, and only the surgical lights illuminated the scene. As the surgical technician handed off the scalpel, the room hummed with a sense of routine efficiency.

But then, the oncoming nurse—a colleague labeled as bossy and overly rigid—spoke up. After receiving report (details about the case, patient, etc.)  from the outgoing OR nurse, she was armed with a flashlight and her stubborn commitment to protocol. Despite the team's assurances that the timeout had been completed, she insisted on personally cross-checking the patient's arm band with the surgical consent form.

Her insistence provoked scorn; eyes rolled accompanied by groans at her insistence. Yet, she still half-crawled to stretch under the surgical drapes in search of the patient’s wrist and armband, paper surgical consent in her other hand for comparison. She shone her flashlight on her target, adjusted her glasses, and scrutinized the details, calling out: "Wait! Stop! I don't think this is the right patient."

The startled surgeon rested the scalpel, the outgoing OR RN clicked off the music, and the room fell silent. I flipped on the overhead lights. As the drapes were peeled back, the diligent OR nurse read aloud from the patient's surgical consent form: patient name, birthdate, and procedure. She then compared this information with the details on the prepped, draped, and anesthetized patient's arm band, reading out loud for everyone to hear: name, birthdate, and procedure.

The info did not match. Wrong patient, wrong OR, wrong surgeon, wrong site, wrong surgery. Wrong.

That flashlight, wielded with courage and conviction, if not saved a life, saved the misery of an incorrect surgery on the patient, likely leading to additional pain, emotional trauma, impact to family, and the impacts go on and on. The impacts are profound and far-reaching.

The silver lining to this real-life near-miss was that it became a powerful catalyst for change. The organization, galvanized by the close call, chose to learn from the incident. They became champions of safety, transforming their practices, and are now role models for patient safety.

Reflecting on Current Trends

In the years since, I have witnessed firsthand the evolution of patient safety protocols and their critical role in healthcare outcomes. However, recent data suggests troubling trends. For instance, the Pennsylvania Patient Safety Authority (PA-PSA) database, often considered a proxy for national trends, indicates a 16% increase in reported patient safety events in Pennsylvania from 2022 to 2023.

Alarmingly, many of these reports involve preventable errors such as wrong-site surgeries, medication mishaps, and lapses in communication.

One critical question arises: Are these increases reflective of more frequent errors, or do they indicate improved reporting mechanisms? While better reporting is a positive development, assuming it accounts for the entirety of the rise could mask significant underlying problems.

Consider the perioperative teams working in your hospital(s) now—how experienced are the  teams, how long have team worked together, and are you hearing of concerning trends or rogue team members? Leaders should explore both possibilities, understanding that improved reporting systems may coexist with an uptick in real events due to systemic stressors.

A Call to Action

The "flashlight incident" symbolizes the vigilance, courage, and commitment needed to overcome today's challenges in healthcare. Illuminate blind spots, equip teams with the tools, training, and trust to ensure safe care. Assume nothing—verify everything. Foster a culture that celebrates vigilance, incentivizes improvement, and prioritizes patient safety.

Building a Culture of Patient Safety

A robust patient safety culture goes beyond policies; it requires active leadership, engaged teams, and a holistic approach.

Executives:

• C-suite leaders can champion patient safety by sharing compelling stories, like the "flashlight incident," to underscore the importance of vigilance.

• Actively validating safety protocol adherence across all shifts and by all staff members helps identify areas for improvement.

• Fostering open communication and a culture where team members can voice concerns without fear of reprisal creates a more trusting and collaborative environment.

• Demonstrate your commitment by visibly supporting safety initiatives, including safety metrics in executive dashboards, and allocating resources for staffing, training, and technology.

Leaders:

• Leaders can enhance their impact by reflecting on the immediate and long-term impact of safety lapses (e.g., wrong-site surgery) on patients and care teams.

• Actively participate in validating safety measures, ensuring accountability across all shifts and team members, and integrating safety processes into the core culture.

Team Empowerment:

• Recognizing and rewarding actions that prevent harm reinforces positive safety behaviors.

Standardization, Training, Audits:

• Standardize critical processes like surgical timeouts and ensure compliance through regular audits.

• Utilize simulation training and ongoing education to enhance critical skills and prepare teams for high-risk scenarios.

Continuous Improvement:

• Encourage a non-punitive reporting system where safety events are used as learning tools.

• Create opportunities for open dialogue and firsthand observations of operations to connect with frontline teams.

• Embed patient safety into the organization's DNA by:

  • Tracking key metrics (adverse events, near-miss reports, training completions) to identify trends and improvement areas.

  • Conducting Root Cause Analyses (RCA) and Failure Modes and Effects Analyses (FMEA) to address underlying issues and proactively mitigate risks.

  • Implementing Lean Six Sigma tools like standard workflows, control charts, and Kaizen events for focused improvement projects.

  • Investing in High-Reliability Organization (HRO) training to build resilience and emphasize continuous improvement.

Partner with KB Kinetics LLC

Navigating patient safety complexities is daunting—but you’re not alone. KB Kinetics LLC specializes in strategies to improve operational excellence and outcomes. We can help.

Our Expertise

• Safety Culture Assessment: Evaluate your culture of safety and receive actionable recommendations.

• HRO Training: Build resilience with high-reliability principles.

• Lean Six Sigma Workshops: Optimize workflows and reduce errors.

• Perioperative Optimization: Enhance safety and efficiency in surgical services.

• Executive Coaching: Develop leaders to champion a culture of safety and accountability.

  
  

Let’s Collaborate

Illuminate your organization’s blind spots and achieve the highest care standards. Schedule a confidential consultation with KB Kinetics LLC today. Together, we can create a safer future for your patients.

Contact Us Email: KBragg@KBKinetics.com or book a confidential consultation now.

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Additional Resources

For those interested in further exploring patient safety, here are some valuable resources:

• The Universal Protocol. The Joint Commission. https://www.jointcommission.org/standards/universal-protocol/

• Agency for Healthcare Research and Quality (AHRQ): Offers a wealth of information on patient safety practices and research. https://www.ahrq.gov/

• Institute for Healthcare Improvement (IHI): Provides resources and training on improving healthcare quality and safety. https://www.ihi.org/

• The Joint Commission: Offers standards and guidelines for healthcare organizations to enhance patient safety. https://www.jointcommission.org/

• National Patient Safety Foundation (NPSF): Focuses on advancing patient safety through education and collaboration. https://psnet.ahrq.gov/issue/national-patient-safety-foundation

• Pennsylvania Patient Safety Authority (PA-PSA): Provides data and insights on patient safety trends and best practices.https://patientsafety.pa.gov/

  
  

  References

• https://patientsafetyj.com/article/116529-patient-safety-trends-in-2023-an-analysis-of-287-997-serious-events-and-incidents-from-the-nation-s-largest-event-reporting-database

• Bragg, K. Perioperative Patient, and Provider Safety Concerns: Systems and Technology. CRNA Today. 2015. Jan; 1-12.

• Bragg K, Schlenk, E, Wolf G, Hoolahan S, Ren X, Henker R. Time out! Surveying surgical barriers. Nursing Management Magazine. 2012 Mar; 43(3):38-44.

• Bragg K, Schlenk, E, Wolf G, Hoolahan S, Ren X, Henker R. Time out! Surveying surgical barriers. OR Nurse. 2012. Sept; 6(5).

• O’Donnell, Bragg K, Sell S. Procedural sedation: Safely navigating the twilight zone. (“O’Donnell, J., Bragg, K. and Sell, S. (2003) Procedural sedation Safely ...”) Nursing 2003:33(4); 36-45.